99090148APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATION/PERMIT PLUMBING
11114 01
CONTACT: `„' O
- PHONE:
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/1rk �/r"~T`_ / J �7 7� / ❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Nat 1 an licensed under provisions of Chapter 9 (commencing
WOZ InSection 7001nofD'wision3ofneBusineaand Prefcaaiona Code, andnry license is
f W O 'n full fora and a t. �.( �a '1� //_ '/ / PERMIT ISSUANCE
CU V I m, Clac v`i-ic. x J Cp J
yZW Dmc Gmrocnr 4�B APPLIANCES - RESIDENTIAL
F, G� A CHII'ECPS DECLARATION PANELS
0... L 1 understand my plans shall be used as public records
'Z UPTO2WAMPS
N F' lei] Licensed Professional JN. nxM ,Oom,
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Comractor'c License Law for the
following mxWor. (Section 7031.5. Buzsand Professions Code: Any city o county
which mgnima permit m emndma, alter,improve, demolish, or repair any smcture
Prior m Ire issuance, nko require, the applicant for such permit to f c a signed nutemeat
that he is licensed porsuanno the provisions of the Contractors License Law (Chapter 9
(conn hearing with Section 7W0) of Division 301 the Business and Profeaim s Code) or
that he i% exempt therefrom and the bales for the alleged cxcmption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pendty of
not more than rise hundred dmFlefs (SSW).
D 1, m owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for eule (Sec. 7W4, Busx
and ProfeaFons Code: The Contmcturs License law docs not apply to an owner of
proth ny who builds or improves broad, and who does such work himself or through
his own employcc, provided that such improvements arc not intended or offered for
sine. If, however the building or improvement is sold within one yea ofcomplabon, the
ownerbuilder will have the burden of proving that he did not huild or Improve for pur-
pose of sale.).
IJ 1. as weer of the property, sm exclusively contracting with licensed contractors to
instruct the project (Sec. 7044, Business and Pmfbaions Code:) The Connector a L[ -
.se Law does not apply to ou owner of propcny who builds or improves thereon, and
who contracts for such projects with a commends) licensed pursuant o the Continuous
License Law
D l am exempt under Sec. ,B&P C for this reason
Date
WORKERS COMPENSATION DECLARATION
PF 1 hereby affirm under parody of perjury one of the following declarations:
LJ I have and will maintain a Cemficate of Comentto%elf-insumforWorkersCompen-
sation, m provided for by Section 37M of the Latin Code, for the performance of the
w
for which this Pemba is Issued.
I have and will main om Worker's Compensation Insurance, as «goired by Section
W of the Labor Code, for the pcifurmance of thework for which this permit is iomu.
My
an on
Zay
Chun,: Walk, 7CE1tTIF�I'E OP 1,. No
WORRENS' �1
COMPENSATION INSURANCE
(Thin section need not be comple edI Vthe permit is formic hmdred dollars ($Ilk)
r less)
1 ccnify that in the performance ofthe work forwhich this permit is issued.) shall
not employ any Person in any manner so as roe become subject ro rhe Workeri Cnmpcn-
OZ alien Lowaof California. Date
Z Applicant
y NOTICE TO APPLICANT: 1f, after making this Certifcale of Excnsption, you aM1nulJ
M1econte subject to the Worker. Compensation provl%ionc of the Labor Cale, you most
forthwith comply with such provisions or this permit shall Na deemed revoked.
1
U Z Catthe iso conNLENDINGAGENCY
U thereby enthu that them isucrd(Sea 3097,lending agency for Performance of
LL p the work for whicM1 ml%permh i%iaaame [sen.3W7, civ. e)
C) U Lender's Name
W Lender's Add..,
G 1 certify that I have read this application and state that the above information is
N muco. l agree or comply with all city and county noblemen and state law%relating to QTY.
°C) Z buddingeornuuclion. and hereby aalhmrne represemahves efmischy to emeruponthe
(We) agree to .save, indemnify and keep hamsless the City of Cupertino against
Imbil itis%, judgments, costs and expenses which may in any way accrue against said City
in comequma of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAPARDOUS MATERIALS DISCLOSURE
Will the applicant nr future building ecuupum sioneor handle hunorduu, material
us defined by the Cupcnino Municipal Code. Chapher 9.12, and the Health and Safety
Code, Section 25532(x):'
Yee Cl No
Will the applteam or future building occupant ace equipment or devices which
nr h:uardouc air contaminants as defined by the Buy Arca Aar Quality Management
❑Yes CNo
I have mad the havallous numdals halmocmenls under Chapter fi 95 of the Cdi-
lo nix IIcahh & Safety Code, Section, 25505. 25533 and 25534. 1 mnderstaud that of the
building does not currently have a moral, that it is my responsibility to notify the ozcupam
of the mgyimmemu which most he met prior to isonar” oft Ccnifscem of Occomancv.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
I EMP. METER OR POLE [NST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQ ET.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLAW PROTECT, DEVICE
DRAINS - FLOOR. ROOF. AREACC'Oo'�f J
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS- EA. SYSTEM -OVER 4 (EA)
GREAS EANDUSTRL WASTE INTERCEPTOR
CREASE ]EAP
SEWER - SANITARY - STORM EA. 200 FT.
WATER HEATER W/VENLUELECTR
WATER SYSTHM(CREATING
WATER SBEV ICF.
NEW RE.SIDENI'IAL PLMB. SQ. Er.
TOTAL:
MECHANICAL PERMIT
PERMITISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (1010.110) CFM)
AIR HANDLING UNIT (OVER 10,0!1!1 CPM)
EXHAUST HOOD(WMUCU
HEATING UNIT(TO IM." BTU)
HEATING UNIT (OVER Ift BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP CHP OR 100,000 BTU)
BOILER - COMP(OVER 100JXX)BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, ET
0
iZ�
BUILDING PERMIT INFO
BLD Eg PLUMB N7
J013 DESCRIPIION
RESIDENTIAL:
D SEDWL
D KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
D MULTLUN'IT
❑STRUCTURAL
MODIFICATION
D INTERIOR
D CHIMNEY REPAIR
IMPROVEMENT
EJ SWIMMING POOLS
D BATH REMODEUREPAIR D DEMOLITION
D OTHER
COMMERCIAL:
C1 NEW BLDG/ADDITION
C1 DEMOLITION
[I TENANT
❑ FOOD SERVICE
IMPROVEMENT
D OTHER
9 SQIj;LiFLOOR AREA
FEE
VALUATION
�'T/
STORIES TYPECI
OCC. GROUP
V
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING IEE
SOILS FEE
PAID
{tl U_Raeipta u
ti� �I r11Yn f�1't
BUILDIh EE SE,` u x IJP
FEE SEISMIC �r}°.Ii
ELECTRIC FEB
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Ilam Rcccipi x 1
TOTAL: ISSUED BY:
OFFICE
SISQ. ET.
7
UANCE DATE
-L7-4a�1
L
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
. BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Blk: Lot:362070II.00
INVOICE DATE......: 09/27/1999
REFERENCE ID n ...: 99090148
SITE ADDRESS .....:
1134 STAFFORD DR
SUBDIVISION .......
CITYCUPERTINO
..............
IMPACT AREA .......
OWNER ............:
WOLNOWSKY HOWARD E AND LOUISE
ADDRESS ..........:
CITY/STATE/ZIP ...:
CUPERTINO CA, -CA 95014-4912
CONTRACTOR .......:
RANDO, JOE LIC N 8050
COMPANY ..........:
A A A FURNACE COMPANY
ADDRESS ..........:
1712 STONE AVE
CITY/STATE/ZIP ...:
SAN JOSE, CA 95125
TELEPHONE ........:
(900)293-4717
FEE DESCRIPTION CHK TOTAL FEE
BREMAIRRAN P 8.33
BREMMISC P 25.53
EPERMITFEE P 35.52
MPERMITFEE P 35.52
109.90
INE ID DESCRIPTION
..sa......m.......
. s.....
303 ROUGH MECHANICAL
505 FINAL ELECTRICAL
40
PAID -TO -DATE BALANCE DUE
0.00 0.33
0.00 25.53
0.00 35.52
0.00 35.52
------------ -----------
0.00 104.90
VOICE ID DESCRIPTION
304 .. ROUGHv ELECTRICAL
508 FINAL MECHANICAL